Surgical equipment in the operating room at Houston Methodist Hospital, where Dr. Eugene Alford works on a patient.

Dr. Eugene Alford is running a little late, but that's OK. His first surgery of the day had to be postponed because the patient forgot to stop taking her aspirin.

So it's on to the next one: a woman in her 50s who had one rhinoplasty (you might call it a nose job) but later was dissatisfied with the look of it and, worse, couldn't breathe through her nose.

Alford - everyone calls him "Dr. Gene" - is the guy you go to for your second-chance nose.

"I have a reputation for dealing with noses that are already messed up," said Dr. Gene, 54, a cheerful man with an impressive mustache. "About half the surgeries I do are revisions."

Dr. Gene, who is married and has three grown children, scrubs up and prepares for surgery in a not-very-large operating room at Houston Methodist in the Texas Medical Center as an assistant helps him with his green surgical gown, cap and gloves. The patient is already anesthetized. Shortly after 10 a.m., the surgery begins.

Like many surgeons, Dr. Gene works to music. He has an eclectic playlist, from Herb Alpert to old-school hip-hop or, as he puts it, "Pat Green to Snoop Dogg." The only time a member of the team lunges for the "skip" button is when a version of "Blue Christmas" comes on.

This will be an "open rhinoplasty," meaning it won't be done from the inside of the nose. Instead, Dr. Gene makes an incision at the base of the nose and peels back the skin, (think of lifting up a slipcover) revealing the cartilage, which is a kind of flexible connective tissue. Later, he explains that the nose has three components: the lining, which makes the mucus; the cartilage and bone, which provide shape and structure; and the skin, which gives the nose its color and appearance. "The only thing we can change is the cartilage and bone, by sculpting," he said.

The patient's cartilage is uneven, and the surgeon will have to do significant reconstruction. There's not enough cartilage in the nose to make that possible.

But Dr. Gene has a trick up his sleeve.

A nose doesn't have cartilage to spare, but an ear does. "Spare parts," he calls it.

Dr. Gene folds over the patient's right ear and deftly carves out a quarter-size disc of milky-white cartilage. No one will ever know, he says, because the ear will retain its structural integrity. It won't change shape at all.

The doctor carves the cartilage into the fingernail-size pieces he will need to restructure the architecture of the patient's nose.

At one point, he also takes a metal file and vigorously hones down some rough spots where the cartilage meets the bone. It's a little disconcerting to watch, but it will, literally, make the patient breathe easier.

And then, about an hour and a half in, the doctor takes a break. Unlike, say, organ-transplant surgery, rhinoplasty is not a race against time.

The break is a good time to mention the other character in this drama, besides the surgeon, the patient and the surgical team, and that is Dr. Gene's chair.

In December 2007, while working on his land in Bellville, Alford was struck by a falling oak tree and the lower half of his body was paralyzed. For a long time, it was unclear whether he would ever operate again. Eventually, with the help of his wheelchair, he did.

The chair, made by Life Stand, is "a standard, off-the-shelf electric wheelchair," he said. But it allows the back and seat to move into a vertical position, giving Dr. Gene a standing posture much like that of any surgeon. (Life Stand was bought by Permobil, which makes a similar but larger chair, and now the smaller chairs are available only in Europe or by special order.)

It's also a good time to mention the surgical team: Deborah Conley, the scrub nurse; Maria Rosales, the circulation nurse; Jennifer Terrazas, the certified registered nurse anesthetist. "I've worked with Maria and Deb on maybe 99 percent of my surgeries for the past 15 years," he said.

They know each other very well. "It should be that way in every operating room," he said.

In the second half of the surgery, Dr. Gene painstakingly re-engineers the structure of the patient's nose. He uses the language of architecture: angles, sidewalls, struts.

Finally, it's time to stitch down the new nose, and that's where Dr. Gene runs into a snag. When he finishes, it's a little crooked. He rips out the stitches and tries again. Still crooked. The third time, it's perfect.

Dr. Gene has seen the patient for office visits twice since the operation. She's still a little swollen, but besides that, she's fully recovered. She reports that she's never been able to breathe through her nose so well.